Manipulation pharmacologique de l'anabolisme : l'exemple de l'hormone de croissance

Optimal enteral or parenteral nutrition is not sufficient to correct protein catabolism during major metabolic stress or to systematically improve protein anabolism in chronic malnutrition. The administration of anabolic factors is therefore logical. The availability of human recombinant growth hormone (rhGH) and Insulin-like Growth Factor-I (rhIGF-I) permits their utilization in cases of metabolic stress and muscle catabolism. Their efficiency has been globally demonstrated. On the other hand, the data regarding possible clinical benefits are practically non-existent and the risk-benefit and cost-benefit ratios require further evaluation.This review summarizes the main clinical studies of rhGH and rhIGF-I and the relationship with catabolism or protein deficit. The main pathophysiological bases are presented.     

Problem-solving in laparoscopic surgery

Summary The advent of the laparoscopic revolution and the wider applicability of laparoscopic procedures has caused surgeons to re-think the dynamics of intraoperative problem-solving. Problems of body habitus, previous surgery, exposure, bleeding, and anesthesia, as well as the problem cholangiogram, require new and innovative approaches. a practical approach to each of these common laparoscopic problems is presented.     

Effects of diclofenac on experimental streptococcal necrotizing fasciitis (NF) in rabbit

Abstract Aggravation of necrotizing fasciitis (NF) by the administration of non-steroidal antiinflammatory drugs (NSAIDs) has recently been suggested. A rabbit model of streptococcal NF was used to study the effects of parenteral administration of an NSAID on NF evolution and outcome. Of 16 rabbits inoculated with a Streptococcus pyogenes suspension together with staphylococcal alpha toxin, 8 were treated with two doses of 4 mg/kg diclofenac on day 1 after inoculation. Clinical, bacteriological and histological studies were performed until day 10. Under our experimental conditions, NSAID treatment significantly limited NF extension. A specific inverse relationship between the extent of inflammation and bacterial density in NF lesions was observed on day 1 after inoculation in the treated group suggesting that the greater severity of NF in humans treated with an NSAID could be due to the therapeutic delay induced by the misleading clinical effects of the NSAID, and not to inhibition of antibacterial defence. Received: 23 October 1997 / Received after revision: 23 June 1998 / Accepted: 30 July 1998     

Hippocampal volumes in cognitively normal persons at genetic risk for Alzheimer's disease

Brain imaging techniques have the potential to characterize neurobiological changes that precede the onset of cognitive impairment in persons at risk for Alzheimer's disease. As previously described, positron emission tomography (PET) was used to compare 11 cognitively normal persons 50 to 62 years of age who were homozygous for the ε4 allele of apolipoprotein E and 22 persons without the ε4 allele with a reported family history of Alzheimer's dementia who were matched for sex, age, and level of education. The ε4 homozygotes had significantly reduced glucose metabolism in the same brain regions as patients with Alzheimer's dementia; the largest reduction was in the posterior cingulate cortex. As described here, magnetic resonance imaging (MRI) was used to compare hippocampal volumes in the same subject groups. The ε4 homozygotes showed nonsignificant trends for smaller left and right hippocampal volumes; overall, smaller hippocampal volumes were associated with reduced performance on a long-term memory test. Whereas PET measurements of cerebral glucose metabolism begin to decrease before the onset of memory decline, MRI measurements of hippocampal volume begin to decrease in conjunction with memory decline in cognitively normal persons at risk for Alzheimer's disease.     

Autonomic control of cardiovascular dynamics during weightlessness

Measuring cardiovascular dynamics is a new method of assessing the autonomic regulation of the cardiovascular system, it provides an easily-implemented non-invasive way of monitoring the effects of weightlessness on this regulatory function. The major findings of studies on cardiovascular dynamics during actual or simulated weightlessness are presented, taking into account the recent consensus on this approach. Future improvements of these studies are discussed.     

Infertility: Higher pregnancy rates with a simple method for Fallopian tube sperm perfusion, using the cervical clamp double nut bivalve speculum in the treatment of unexplained infertility: a prospective randomized study

The object of this study was to evaluate the efficacy of thenewly developed cervical clamp double nut bivalve (DNB) speculumused for Fallopian tube sperm perfusion (FSP) with 4 ml of theinseminate, in comparison with standard intrauterine insemination(IUI) using a volume of 0.5 ml of the inseminate. Couples withunexplained infertility (n = 104), undergoing 202 cycles, wereenrolled in this study. Cycles were assigned randomly to eitherIUI (group A, n = 92) or FSP + DNB speculum^® (group B, n= 110). Ovarian stimulation was achieved using three differentovarian stimulation protocols in both groups. The age and folliculardevelopment of the patients were similar in both groups. Theserum hormonal measurements and the endometrial thickness wasalso similar on the day of human chorionic gonadotrophin (HCG)administration. The mean (± SD) number of motile spermatozoainseminated was 44.83 ± 16.57 x 10⁶ in group A and 42.68± 13.44 x 10⁶ in group B. In group A (IUI), 11 clinicalpregnancies (presence of gestational sac with heart beats) occurred(11.95% per cycle). In group B (FSP + DNB speculum^®) 29clinical pregnancies occurred (26.36% per cycle). These differenceswere statistically significant (P <0.001). The results ofthis study for the treatment of unexplained infertility indicatethat this simple, well tolerated, inexpensive method of usingthe DNB speculum for FSP is more successful than standard IUI.     

Preoperative Clinical Assessment of Hemostatic Function in Patients Scheduled for a Cardiac Operation

Background. Bleeding during and after cardiac operations is usually attributed to inadequate surgical hemostasis or cardiopulmonary bypass-induced disorders of hemostasis. Patient-related factors often are neglected.

Methods. Articles published between 1976 and 1996 on the preoperative assessment of surgical patients were reviewed to determine the clinical elements most likely to predict increased perioperative blood requirements.

Results. Preoperative assessment is based on a carefully conducted interview (history of bruising, petechiae, recent or excessive bleeding after operation, chronic drug therapy) and physical examination. A standardized questionnaire to enhance the reliability of the assessment is presented. Thus, patients at high risk of being transfused can be identified early on and may be enrolled in various programs designed to decrease bleeding and the need for allogeneic blood transfusions.

Conclusions. Clinical assessment of hemostatic function before cardiac operations is both effective and efficient. It obviates the need for routine laboratory testing and favors the introduction of blood conservation strategies early on during the process of care.     

Paraspinal mapping: Quantified needle electromyography in lumbar radiculopathy

In the diagnosis of low back pain, the presence of a high percentage of false positive findings on radiologic imaging studies has lead to a more definitive role for electrodiagnosis as a confirmatory test. The paraspinal muscles are a crucial part of the electrodiagnostic examination for radiculopathy. To date, no technique for paraspinal evaluation has been validated. Based on previously documented anatomical techniques, we have designed a method of paraspinal examination termed “paraspinal mapping” (PM). Electromyographic (EMG) needles are placed in five carefully chosen locations and inserted in multiple directions. Individual scores for these insertions are added to determine a total PM sensitivity score. The first 50 studies using PM were compared to peripheral EMG, imaging studies, and pain drawings. Results indicate that the technique is easy to perform. Sensitivity scores relate well with these tests. In this limited and uncontrolled population, PM had higher sensitivity for abnormalities than either peripheral EMG or imaging studies. Because of the anatomical validity of PM, future studies may show it to be useful in localizing the level of radiculopathy independently from peripheral EMG, and to support clinical findings and imaging studies. © 1993 John Wiley & Soncs, Inc.     

Iodine-131 MIBG scintigraphy in small cell lung cancer

There is a well documented relationship between small cell carcinoma of the lung and the amine precursor uptake and decarboxylation system of endocrine cells (APUD). We attempted to exploit this association by employing the unique radiopharmaceutical,¹³¹I-MIBG, which is recognized and taken up by the APUD system to monitor disease activity in patients with small cell carcinoma of the lung. A total of eight patients with biopsy proven, metastatic small cell carcinoma of the lung were studied.¹³¹I-MIBG was synthesized in our laboratory by reacting metaiodobenzylamine synthesized in our laboratory by reacting metaiodobenzylamine hydrochloride with cyanamide with subsequent solid phase radioiodination. A dose of 0.5 mCi radiopharmaceutical was injected and images obtained on a large field of view gamma camera with a high energy parallel hole collimator at 2, 24, and either 48 or 72 h. Images were compared with known focal areas of metastatic disease demonstrable on computed tomographic scan, chest roentgenogram or bone scan. We were unable to detect reproducible correlations between the images produced by conventional radiographic techniques and the images produced by our radiopharmaceutical. We conclude that this agent will probably not be useful for localization of metastatic small cell lung carcinoma.This work was supported by a Pilot Research Grant from the Education and Research Foundation of the Society of Nuclear Medicine     

Cholangiographic features in fibrosis and cirrhosis of the liver

The cholangiographic features of intrahepatic bile ducts associated with cirrhosis or fibrosis are not well known. In order to achieve a radiological—pathological correlation, we studied nine livers with fibrosis or cirrhosis excised at autopsy. Cholangiograms were obtained within 24 hr after death from the nonfixed liver and multiple tissues samples were taken for histologic examination. Radiological data were interpreted by two independent investigators blinded to the clinical and histological findings. Cirrhosis (alcoholic in 4, posthepatitis in two) was observed in six livers, fibrosis (alcoholic in 2, posthepatitis in one) in three. No liver with fibrosis had cholangiographic abnormalities. In contrast, cholangiography of all livers with cirrhosis was abnormal. Abnormalities were a diminished arborization, a decrease of the distal opacification, an irregularity of caliber, and a tortuous course of the bile ducts. Histological study showed that the irregular and tortuous course were due to compression of the bile ducts by regenerative nodules. Furthermore, a thick fibrosis was organized around the bile ducts. In conclusion, fibrosis alone was not associated with cholangiographic abnormalities. In cirrhotic livers, intrahepatic bile ducts showed an irregular and tortuous course, a diminished arborization and a decrease of the distal opacification. These abnormalities were secondary to the presence of regenerative nodules and fibrosis organized around the bile ducts.